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Do mental and physical health trajectories change around transitions into sandwich care? Results from the UK household longitudinal study.
Get PDFOBJECTIVES: Sandwich carers provide care to ageing parents or older relatives while simultaneously raising dependent children. There has been little focus on how mental and physical health trajectories change around becoming a sandwich carer - a gap this study aims to fill. STUDY DESIGN: Prospective longitudinal study. METHODS: We used 10 waves of data from the UK Household Longitudinal Study (2009-2020) - a high-quality longitudinal data. Sandwich carers were parents who lived with children under age 16 and took up unpaid care of a family member in the older generation. Sandwich carers were matched with parents who did not take up any adult care (i.e., non-sandwiched parents) with similar characteristics. We then employed piecewise growth curve modelling to model the trajectories in mental and physical health before, during and after becoming a sandwich carer and comparing these with non-sandwiched parents. RESULTS: Among parents, the uptake of caring for a family member was associated with a deterioration in mental health, especially for those who spent more than 20 h per week caring for a family member. The deterioration persisted for several years. Those who cared intensively also experienced greater physical health declines during the transition. We did not see evidence of gender difference in the above associations. CONCLUSIONS: It is essential for society to recognise the unique needs and challenges of sandwich carers and provide them with the necessary support systems, resources, and community networks to ensure their health is maintained. Targeted support is required for sandwich carers who care intensively
Systematic Review, Meta-analysis, and Time to Event Analysis of Contemporary Mortality after Major Lower Limb Amputation for Peripheral Arterial Disease or Diabetes Mellitus
Get PDFObjective
Major lower limb amputation for peripheral arterial disease (PAD) or diabetes mellitus carries high mortality risk. This time to event and meta-analysis reports contemporary survival and subgroup risk factor analysis.
Data Sources
MEDLINE, Embase, and Cochrane libraries.
Review Methods
This was a systematic review, meta-analysis, and time to event analysis of contemporary literature performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42024497352). MEDLINE, Embase, and Cochrane libraries were searched on 2 December 2023, limited to 5 years and independently screened by two reviewers. All studies reporting mortality for patients undergoing major lower limb amputation for PAD or diabetes were included. Study quality and evidence certainty were evaluated via Risk of Bias 2, Newcastle–Ottawa, and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tools, respectively. Mean values weighted by study size were used for short term mortality estimation, pooled time to event survival analysis for mid to long term, and random effects modelling for subgroup meta-analysis.
Results
A total of 7 537 unique studies were screened, with 140 meeting criteria for inclusion. Short term mortality was estimated by weighted mean at 6.5% (range 1.8 – 34.1%) in hospital and 8.7% (0 – 26.8%) at 30 days (low GRADE certainty). Pooled time to event analysis was possible across 19 studies with 59 999 patients included. Estimated mortality was 28.9% at 1 year and 63.0% at 5 years with a median survival of 3.1 years (moderate GRADE certainty). Meta-analysed subgroup data demonstrated end stage renal disease, heart failure, frailty, and higher level amputation all increase mortality with peak odds ratios of 5.57, 2.14, 2.25, and 2.30, respectively. Diabetes was not associated with mortality. The time to event analysis for diabetes and level subgroups corroborated these results. Median survival for patients with diabetes was 2.7 years (95% confidence interval 2.0 – 3.5 years) compared with 3.1 years (1.9 – 4.7 years) for those with PAD alone. Subgroup analyses were of very low to moderate GRADE certainty.
Conclusion
Contemporary mortality after major lower limb amputation for PAD or diabetes remains high. End stage renal disease, heart failure, frailty, and higher level of amputation were all associated with mortality risk
Reactogenicity and immunogenicity following heterologous and homologous third dose COVID-19 vaccination in UK adolescents (Com-COV3): A randomised controlled non-inferiority trial
Get PDFBACKGROUND: The emergence of SARS-CoV2 variants combined with waning vaccine-induced immunity and breakthrough infections has highlighted the need for booster doses to maintain protection against SARS-CoV2 infection and disease. METHODS: Com-COV3 was a phase II, multicentre, randomised controlled trial, recruiting across 11 UK sites from June 2022 to June 2023, with follow-up visits to February 2024. Healthy 12-15-year-olds who had received a two-30 μg dose BNT162b2 primary regimen at least 90 days previously were randomised 1:1:1:1:1 to receive either BNT162b2 30 μg, BNT162b2 10 μg (adult vaccine formulation), BNT162b2 10 μg (paediatric formulation), NVXCoV2373, or Meningococcal B vaccine (control). The primary objective was to determine if SARS-CoV-2 anti-spike antibody following a 10 μg dose of the adult formulation of BNT162b2 was non-inferior to the paediatric formulation at 28 days post-third vaccination. The last five participants were randomised using a 1:3:3:1:1 ratio to prioritise recruitment to the study groups required for the co-primary endpoint. Although recruitment ceased early, the sample size required to fulfil the primary objective was met. FINDINGS: 281 participants were recruited (mean age 14 years old, 57% female). Adverse reactions were mostly mild-to-moderate. Local reactogenicity was mildest following NVXCoV2373. Frequency of adverse events was similar for both full dose and fractional dose BNT162b2 groups. Four serious adverse events occurred: three in the paediatric and one in the adult 10 μg BNT162b2 group. Immunogenicity of 10 μg BNT162b2 (adult) was both non-inferior and superior to that of 10 μg BNT162b2 (paediatric); adjusted geometric mean ratio (aGMR) anti-spike IgG 1.50 (one-sided 95% CI 1.25 to ∞). Compared with 30 μg BNT162b2, anti-spike IgG at day 28 post-third dose were similar in the 10 μg BNT162b2 (adult) group [aGMR 0.93 (95% CI 0.75-1.14)] and significantly lower in the 10 μg BNT162b2 (paediatric) [aGMR 0.64 (95% CI 0.52-0.78)] and NVXCoV2373 [aGMR 0.77 (95% CI 0.63-0.95)] groups. Compared with 30 μg BNT162b2, levels of neutralising antibodies against Omicron BA.5 and XBB.15 were similar across vaccine groups. INTERPRETATION: All booster regimens evaluated elicited a robust immune response. 10 μg fractional adult BNT162b2 vaccine demonstrated similar immunogenicity compared with 30 μg BNT162b2 and superior immunogenicity compared with 10 μg paediatric BNT162b2 vaccine. Fractional doses of the adult BNT162b2 vaccine are an alternative to the paediatric formulation for booster campaigns in adolescents
Seasonal Variation in Sudden Cardiac Death: Insights from a Large United Kingdom Registry
Get PDFBackground
Sudden cardiac death (SCD) is relatively common and may occur in apparently healthy individuals. The role of seasonal variation as a risk factor for SCD is poorly understood. The aim of this study was to investigate whether SCD exhibits a predilection for specific seasons.
Methods
We reviewed a database of 4751 cases of SCD (mean age 38 ± 17 years) referred to our center for cardiac pathology at St George’s University of London between 2000 and 2018. Clinical information was obtained from referring coroners who were asked to complete a detailed questionnaire. All cases underwent macroscopic and histological evaluation of the heart, by expert cardiac pathologists.
Results
SCD was more common during winter (26%) and rarer during summer (24%), p= 0.161. Significant seasonal variation was not observed among cases of sudden arrhythmic death syndrome (SADS, 2910 cases) in which the heart is structurally normal. In contrast, a significant difference in seasonal distribution among decedents exhibiting cardiac structural abnormalities at the post-mortem examination (n=1841) was observed. In this subgroup, SCDs occurred more frequently during winter (27 %) compared to summer (22%) (p=0.007). In cases diagnosed with a myocardial disease (n=1399), SCD was most common during the winter (27%) and least common during the summer (22%) (p=0.027).
Conclusions
While SADS occurs throughout the year with no seasonal variation, SCD due to structural heart disease appears to be more common during the winter. Bio-meteorological factors may be potential triggers of SCD in individuals with an underlying structural cardiac abnormality
Does young adulthood caring influence educational attainment and employment in the UK and Germany?
Get PDFInformal care plays an important role in the provision of care. However, previous research has mainly focused on middle- or older-aged informal carers and less is known about informal care among young adults, its consequences on educational achievement and employment transitions and whether this varies across country contexts. Using data from the 2009–2018 waves of the UK Household Longitudinal Study (N = 25,856) and the German Socio-Economic Panel (N = 16,666), we investigated the influence of informal care responsibilities of 17–29 year olds on their chances of achieving a university degree using logistic regression and employment transitions using Cox proportional hazard regression models. Our results revealed that young adulthood caring was negatively associated with the likelihood of obtaining a university degree, reduced the likelihood of entering employment and increased the likelihood of unemployment. These associations were more pronounced if people reported caring for more weekly hours (especially in the UK) or caring for longer durations (especially in Germany). The potential negative influence of caring in young adulthood on education was stronger for women than for men in Germany, and the influence of caring on entering unemployment was stronger for women than for men in the UK
Suspected de novo heart failure in outpatient care: the REVOLUTION HF study.
Get PDFBACKGROUND AND AIMS: Ambulatory patients presenting with signs or symptoms of heart failure (HF) should undergo natriuretic peptide testing. Rates of death, HF hospitalization, and healthcare costs were examined in patients thus identified with suspected de novo HF. METHODS: This population-based study (REVOLUTION HF) encompassing two large healthcare regions in Sweden examined patients who presented to outpatient care for the first time between 1 January 2015 and 31 December 2020, who had a recorded sign (peripheral oedema) or symptom (dyspnoea) of HF, and whose N-terminal pro-B-type natriuretic peptide (NT-proBNP) measured >300 ng/L within ±30 days of that sign or symptom. Characteristics, outcomes, healthcare patterns, and healthcare costs for these patients were followed for 1 year. Comparisons were made with matched controls without history of HF, its signs, its symptoms, or elevated NT-proBNP. RESULTS: Overall, 5942 patients (median age 78.7 years; 54% women) presented with suspected de novo HF. Within 1 year, 29% had received a HF diagnosis. Patients with suspected de novo HF had higher rates of all-cause death (11.7 vs. 6.5 events/100 person-years) and HF hospitalizations (12.5 vs. 2.2 events/100 person-years) than matched controls (n = 2048), with the highest event rates in the weeks after presentation. Rates were higher with higher NT-proBNP levels. Although some patients already used HF guideline-directed medical therapies for other indications, initiation of new medications was variable. Healthcare costs were higher in patients with suspected de novo HF than in matched controls, driven mostly by HF and chronic kidney disease. CONCLUSIONS: Patients with suspected HF and elevated NT-proBNP had high mortality and morbidity in the weeks after presentation, and accrued substantial healthcare costs, highlighting an urgent need for prompt identification, evaluation, and treatment of HF
Design and rationale of MYOFLAME-19 randomised controlled trial: MYOcardial protection to reduce post-COVID inFLAMmatory heart disease using cardiovascular magnetic resonance Endpoints.
Get PDFBACKGROUND: Cardiac symptoms due to postacute inflammatory cardiac involvement affect a broad segment of previously well people with only mild acute coronavirus disease 2019 (COVID-19) illness and without overt structural heart disease. Cardiovascular magnetic resonance (CMR) imaging can identify the underlying subclinical disease process, which is associated with chronic cardiac symptoms. Specific therapy directed at reducing postacute cardiac inflammatory involvement before development of myocardial injury and impairment is missing. METHODS: Prospective multicenter randomized placebo-controlled study of myocardial protection therapy (combined immunosuppressive/antiremodeling) of low-dose prednisolone and losartan. Consecutive symptomatic individuals with a prior COVID-19 infection, no pre-existing significant comorbidities or structural heart disease, undergo standardized assessments with questionnaires, CMR imaging, and cardiopulmonary exercise testing (CPET). Eligible participants fulfilling the criteria of subclinical post-COVID inflammatory heart involvement on baseline CMR examination are randomized to treatment with either verum or placebo for a total of 16 weeks (W16). Participants and investigators remain blinded to the group allocation throughout the study duration. The primary efficacy endpoint is the absolute change of left ventricular ejection fraction to baseline at W16, measured by CMR, between the verum treatment and placebo group by absolute difference, using unpaired t-test confirmatively at a significance level of 0.05 significance level. Secondary endpoints include assessment of changes of symptoms, CMR parameters, and CPET after W16, and frequency of major adverse cardiac events after 1 year. Safety data will be analyzed for frequency, severity, and types of adverse events (AEs) for all treatment groups. The proportion of AEs related to the contrast agent gadobutrol will also be analyzed. A calculated sample size is a total of 280 participants (accounting for 22 subjects (8%) drop out), randomized in 1:1 fashion to 140 in the verum and 140 placebo groups. CONCLUSION: Myoflame-19 study will examine the efficacy of a myocardial protection therapy in symptomatic participants with post-COVID inflammatory cardiac involvement determined by CMR. The aim of the intervention is to reduce the symptoms and inflammatory myocardial injury, improve exercise tolerance, and preclude the development of cardiac impairment
Iron management and exercise training in individuals with chronic kidney disease: lived experiences.
Get PDFBACKGROUND: Non-anaemic iron deficiency is highly prevalent in people living with chronic kidney disease (CKD) but is underdiagnosed and undertreated, especially in earlier stages of CKD. A multicentre trial assessing the effect of intravenous iron supplementation in iron-deficiency but not anaemic people with CKD included a qualitative sub-study that aimed to explore the patient experience and psychosocial impact of living with CKD and iron deficiency, and the experience of the therapeutic intervention (intravenous iron and exercise). METHODS: Semi-structured interviews were conducted with 23 trial participants blinded to treatment. Topics explored included experiences of living with CKD and iron deficiency, symptoms, social and leisure activities, quality of life, and participants' views and experiences of receiving the therapeutic intervention. Thematic analysis was used to identify and report themes. RESULTS: Six overarching themes were identified: lack of awareness of iron deficiency; overwhelming feelings of tiredness; feeling limited; balancing emotions; perceptions and experiences of therapeutic treatment received; and impact of trial participation on life participation. Trial participation, specifically the exercise training, was perceived to be beneficial, with improvements in life participation and psychological wellbeing experienced. However, there were no clear differences between treatment groups, with mixed perceptions about which therapeutic treatment was received. CONCLUSIONS: The impact of tiredness on individuals with CKD is profound and can result in reduced vitality, impaired ability to engage in life activities and emotional conflict. Improved communication and support about psychosocial impact and management of symptoms, particularly fatigue, for people with CKD may be required, alongside effective therapeutic interventions, to improve symptom management and quality of life
Low-dose digoxin improves cardiac function in patients with heart failure, preserved ejection fraction and atrial fibrillation – the RATE-AF randomized trial
Get PDFAims
To compare the effect of digoxin versus beta-blockers on left ventricular function, in patients with permanent atrial fibrillation (AF) and symptoms of heart failure within the RATE-AF randomized trial.
Methods and results
Blinded echocardiograms were performed at baseline and 12-month follow-up using a pre-defined imaging protocol and the index-beat approach. The change in systolic and diastolic function was assessed, stratified by left ventricular ejection fraction (LVEF). Overall, 145 patients completed follow-up, with median age 75 years (interquartile range 69–82) and 44% women. In 119 patients with baseline LVEF ≥50%, a significantly greater improvement in systolic function was noted in patients randomized to low-dose digoxin versus beta-blockers: adjusted mean difference for LVEF 2.3% (95% confidence interval [CI] 0.3–4.2; p = 0.021), s′ 1.1 cm/s (95% CI 1.0–1.2; p = 0.001) and stroke volume 6.5 ml (95% CI 0.4–12.6; p = 0.037), with no difference in global longitudinal strain (p = 0.11) or any diastolic parameters. There were no significant differences between groups for patients with LVEF 40–49% and <40%. Digoxin reduced N-terminal pro-B-type natriuretic peptide compared to beta-blockers (geometric mean difference 0.77; 95% CI 0.64–0.92; p = 0.004), improved New York Heart Association functional class (odds ratio [OR] 11.3, 95% CI 4.3–29.8; p < 0.001) and modified European Heart Rhythm Association arrhythmia symptom class (OR 4.91, 95% CI 2.36–10.23; p < 0.001), with substantially less adverse events (incident rate ratio 0.21, 95% CI 0.13–0.31; p < 0.001). There were no interactions between treatment effects and baseline LVEF for these outcomes (interaction p = 0.62, 0.49, 0.07 and 0.13, respectively).
Conclusions
Low-dose digoxin in patients with symptoms of heart failure, preserved LVEF and permanent AF leads to a significantly greater improvement in systolic function compared to treatment with beta-blockers
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